Korean J Ophthalmol.  2019 Dec;33(6):557-568. 10.3341/kjo.2019.0061.

Current Management of Childhood Amblyopia

• Park SH

• KMID: 2465136
• DOI: http://doi.org/10.3341/kjo.2019.0061

Abstract

Amblyopia is defined as the reduction of best-corrected visual acuity of one or both eyes caused by conditions that affect normal visual development. The basic strategy to treat amblyopia is to obtain a clear retinal image in each eye and correct ocular dominance through forced use of the amblyopic eye. Treatment modalities include correcting any underlying organic disease, prescribing appropriate optical correction, and providing occlusion/penalization therapy for the non-amblyopic eye. Given the success of amblyopia treatment declines with increasing age, the detection and management of amblyopia should begin as early as possible during the sensitive period for visual development. Proper management of amblyopia during childhood can reduce the overall prevalence and severity of visual loss. This study aims to provide an update for the management of childhood amblyopia to provide better visual outcomes.

Keyword

Amblyopia; Optical correction; Patching; Pharmacologic treatment

MeSH Terms

Amblyopia*
Dominance, Ocular
Prevalence
Retinaldehyde
Visual Acuity
Retinaldehyde

Figure

• 

  Fig. 1 A stepwise approach to treating childhood amblyopia. VA = visual acuity.

Reference

1. Wallace DK, Repka MX, Lee KA, et al. Amblyopia preferred practice pattern. Ophthalmology. 2018; 125:P105–P142.

2. Weinacht S, Kind C, Monting JS, Gottlob I. Visual development in preterm and full-term infants: a prospective masked study. Invest Ophthalmol Vis Sci. 1999; 40:346–353.

3. Daw NW. Critical periods and amblyopia. Arch Ophthalmol. 1998; 116:502–505.

4. Gaier ED, Hunter DG. Advances in amblyopia treatment: paradigm shifts and future directions. Int Ophthalmol Clin. 2017; 57:117–128.

5. Eibschitz-Tsimhoni M, Friedman T, Naor J, et al. Early screening for amblyogenic risk factors lowers the prevalence and severity of amblyopia. J AAPOS. 2000; 4:194–199.

6. Kvarnstrom G, Jakobsson P, Lennerstrand G. Visual screening of Swedish children: an ophthalmological evaluation. Acta Ophthalmol Scand. 2001; 79:240–244.

7. Chang JH. Infant and toddler vision care: a supplement to the manual of infant health screening conducted by Korean National Health Insurance Corporation. J Korean Med Assoc. 2013; 56:504–510.

8. Blakemore C, van Sluyters RC. Reversal of the physiological effects of monocular deprivation in kittens: further evidence for a sensitive period. J Physiol. 1974; 237:195–216.

9. Rauschecker JP, Schrader W, von Grunau MW. Rapid recovery from monocular deprivation in kittens after specific visual training. Clin Vis Sci. 1987; 1:257–268.

10. Mohan K, Saroha V, Sharma A. Successful occlusion therapy for amblyopia in 11- to 15-year-old children. J Pediatr Ophthalmol Strabismus. 2004; 41:89–95.

11. Holmes JM, Lazar EL, Melia BM, et al. Effect of age on response to amblyopia treatment in children. Arch Ophthalmol. 2011; 129:1451–1457.

12. Wallace DK, Morse CL, Melia M, et al. Pediatric Eye Evaluations Preferred Practice Pattern: I. vision screening in the primary care and community setting; II. comprehensive ophthalmic examination. Ophthalmology. 2018; 125:P184–P227.

13. Wallace DK, Chandler DL, Beck RW, et al. Treatment of bilateral refractive amblyopia in children three to less than 10 years of age. Am J Ophthalmol. 2007; 144:487–496.

14. Moseley MJ, Neufeld M, McCarry B, et al. Remediation of refractive amblyopia by optical correction alone. Ophthalmic Physiol Opt. 2002; 22:296–299.

15. Cotter SA, Edwards AR, et al. Pediatric Eye Disease Investigator Group. Treatment of anisometropic amblyopia in children with refractive correction. Ophthalmology. 2006; 113:895–903.

16. Scheiman MM, Hertle RW, Beck RW, et al. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol. 2005; 123:437–447.

17. Cotter SA, Edwards AR, Arnold RW, et al. Treatment of strabismic amblyopia with refractive correction. Am J Ophthalmol. 2007; 143:1060–1063.

18. Writing Committee for the Pediatric Eye Disease Investigator Group. Cotter SA, Foster NC, et al. Optical treatment of strabismic and combined strabismic-anisometropic amblyopia. Ophthalmology. 2012; 119:150–158.

19. Holmes JM, Kraker RT, Beck RW, et al. A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmology. 2003; 110:2075–2087.

20. Repka MX, Beck RW, Holmes JM, et al. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol. 2003; 121:603–611.

21. Pediatric Eye Disease Investigator Group. A randomized trial of near versus distance activities while patching for amblyopia in children aged 3 to less than 7 years. Ophthalmology. 2008; 115:2071–2078.

22. Pediatric Eye Disease Investigator Group. Wallace DK, Lazar EL, et al. A randomized trial of increasing patching for amblyopia. Ophthalmology. 2013; 120:2270–2277.

23. Wallace DK, Lazar EL, Crouch ER 3rd, et al. Time course and predictors of amblyopia improvement with 2 hours of daily patching. JAMA Ophthalmol. 2015; 133:606–609.

24. Brown MH, Edelman PM. Conventional occlusion in the older amblyope. Am Orthopt J. 1976; 26:34–36.

25. Koc F, Ozal H, Yasar H, Firat E. Resolution in partially accommodative esotropia during occlusion treatment for amblyopia. Eye (Lond). 2006; 20:325–328.

26. Repka MX, Holmes JM, Melia BM, et al. The effect of amblyopia therapy on ocular alignment. J AAPOS. 2005; 9:542–545.

27. Repka MX, Cotter SA, Beck RW, et al. A randomized trial of atropine regimens for treatment of moderate amblyopia in children. Ophthalmology. 2004; 111:2076–2085.

28. Pediatric Eye Disease Investigator Group. The course of moderate amblyopia treated with atropine in children: experience of the amblyopia treatment study. Am J Ophthalmol. 2003; 136:630–639.

29. Repka MX, Wallace DK, Beck RW, et al. Two-year follow-up of a 6-month randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol. 2005; 123:149–157.

30. Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol. 2002; 120:268–278.

31. Repka MX, Kraker RT, Beck RW, et al. Treatment of severe amblyopia with weekend atropine: results from 2 randomized clinical trials. J AAPOS. 2009; 13:258–263.

32. Simons K, Gotzler KC, Vitale S. Penalization versus parttime occlusion and binocular outcome in treatment of strabismic amblyopia. Ophthalmology. 1997; 104:2156–2160.

33. Nishizawa AR, Orton RB, Cadera W. Comparison of 0.5% cyclopentolate plus 0.5% tropicamide and 1% cyclopentolate alone for mydriasis of dark irides. Can J Ophthalmol. 1988; 23:299–300.

34. Park SH, Park SM, Cho AR, Park SH. Pharmacologic effects of atropine penalization in amblyopic eyes. J Korean Ophthalmol Soc. 2014; 55:590–595.

35. Repka MX, Kraker RT, Holmes JM, et al. Atropine vs patching for treatment of moderate amblyopia: follow-up at 15 years of age of a randomized clinical trial. JAMA Ophthalmol. 2014; 132:799–805.

36. Quah BL, Tay MT, Chew SJ, Lee LK. A study of amblyopia in 18-19 year old males. Singapore Med J. 1991; 32:126–129.

37. Epelbaum M, Milleret C, Buisseret P, Dufier JL. The sensitive period for strabismic amblyopia in humans. Ophthalmology. 1993; 100:323–327.

38. Simmers AJ, Gray LS. Improvement of visual function in an adult amblyope. Optom Vis Sci. 1999; 76:82–87.

39. Pediatric Eye Disease Investigator Group. A prospective, pilot study of treatment of amblyopia in children 10 to <18 years old. Am J Ophthalmol. 2004; 137:581–583.

40. Lee YR, Lee JY. Part-time occlusion therapy for anisometropic amblyopia detected in children eight years of age and older. Korean J Ophthalmol. 2006; 20:171–176.

41. Wallace MP, Stewart CE, Moseley MJ, et al. Compliance with occlusion therapy for childhood amblyopia. Invest Ophthalmol Vis Sci. 2013; 54:6158–6166.

42. Vagge A, Nelson LB. Compliance with the prescribed occlusion treatment for amblyopia. Curr Opin Ophthalmol. 2017; 28:454–459.

43. Newsham D. Parental non-concordance with occlusion therapy. Br J Ophthalmol. 2000; 84:957–962.

44. Newsham D. A randomised controlled trial of written information: the effect on parental non-concordance with occlusion therapy. Br J Ophthalmol. 2002; 86:787–791.

45. Sachdeva V, Mittal V, Kekunnaya R, et al. Efficacy of split hours part-time patching versus continuous hours parttime patching for treatment of anisometropic amblyopia in children: a pilot study. Br J Ophthalmol. 2013; 97:874–878.

46. Kim SJ, Jeon H, Jung JH, et al. Comparison between over-glasses patching and adhesive patching for children with moderate amblyopia: a prospective randomized clinical trial. Graefes Arch Clin Exp Ophthalmol. 2018; 256:429–437.

47. Wang J, Jin J, Malik A, et al. Feasibility of monitoring compliance with intermittent occlusion therapy glasses for amblyopia treatment. J AAPOS. 2019; 23:205.

48. Spierer A, Raz J, Benezra O, et al. Treating amblyopia with liquid crystal glasses: a pilot study. Invest Ophthalmol Vis Sci. 2010; 51:3395–3398.

49. Erbagci I, Okumus S, Oner V, et al. Using liquid crystal glasses to treat ambyopia in children. J AAPOS. 2015; 19:257–259.

50. Wang J, Neely DE, Galli J, et al. A pilot randomized clinical trial of intermittent occlusion therapy liquid crystal glasses versus traditional patching for treatment of moderate unilateral amblyopia. J AAPOS. 2016; 20:326–331.

51. Gibson EJ. Perceptual learning. Annu Rev Psychol. 1963; 14:29–56.

52. Polat U. Restoration of underdeveloped cortical functions: evidence from treatment of adult amblyopia. Restor Neurol Neurosci. 2008; 26:413–424.

53. Campbell FW, Hess RF, Watson PG, Banks R. Preliminary results of a physiologically based treatment of amblyopia. Br J Ophthalmol. 1978; 62:748–755.

54. Levi DM, Polat U, Hu YS. Improvement in Vernier acuity in adults with amblyopia. Practice makes better. Invest Ophthalmol Vis Sci. 1997; 38:1493–1510.

55. Polat U, Ma-Naim T, Belkin M, Sagi D. Improving vision in adult amblyopia by perceptual learning. Proc Natl Acad Sci U S A. 2004; 101:6692–6697.

56. Xi J, Jia WL, Feng LX, et al. Perceptual learning improves stereoacuity in amblyopia. Invest Ophthalmol Vis Sci. 2014; 55:2384–2391.

57. Hess RF, Mansouri B, Thompson B. A new binocular approach to the treatment of amblyopia in adults well beyond the critical period of visual development. Restor Neurol Neurosci. 2010; 28:793–802.

58. Knox PJ, Simmers AJ, Gray LS, Cleary M. An exploratory study: prolonged periods of binocular stimulation can provide an effective treatment for childhood amblyopia. Invest Ophthalmol Vis Sci. 2012; 53:817–824.

59. Birch EE, Li SL, Jost RM, et al. Binocular iPad treatment for amblyopia in preschool children. J AAPOS. 2015; 19:6–11.

60. Holmes JM, Manh VM, Lazar EL, et al. Effect of a binocular iPad game vs part-time patching in children aged 5 to 12 years with amblyopia: a randomized clinical trial. JAMA Ophthalmol. 2016; 134:1391–1400.

61. Kelly KR, Jost RM, Dao L, et al. Binocular iPad game vs patching for treatment of amblyopia in children: a randomized clinical trial. JAMA Ophthalmol. 2016; 134:1402–1408.

62. Manh VM, Holmes JM, Lazar EL, et al. A randomized trial of a binocular iPad game versus part-time patching in children aged 13 to 16 years with amblyopia. Am J Ophthalmol. 2018; 186:104–115.

63. Pediatric Eye Disease Investigator Group. Holmes JM, Manny RE, et al. A randomized trial of binocular Dig Rush game treatment for amblyopia in children aged 7 to 12 years. Ophthalmology. 2019; 126:456–466.

64. Gao TY, Guo CX, Babu RJ, et al. Effectiveness of a binocular video game vs placebo video Game for improving visual functions in older children, teenagers, and adults with amblyopia: a randomized clinical trial. JAMA Ophthalmol. 2018; 136:172–181.

65. Barker AT, Jalinous R, Freeston IL. Non-invasive magnetic stimulation of human motor cortex. Lancet. 1985; 1:1106–1107.

66. Hess RF, Thompson B. New insights into amblyopia: binocular therapy and noninvasive brain stimulation. J AAPOS. 2013; 17:89–93.

67. Thompson B, Mansouri B, Koski L, Hess RF. Brain plasticity in the adult: modulation of function in amblyopia with rTMS. Curr Biol. 2008; 18:1067–1071.

68. Iuvone PM, Tigges M, Fernandes A, Tigges J. Dopamine synthesis and metabolism in rhesus monkey retina: development, aging, and the effects of monocular visual deprivation. Vis Neurosci. 1989; 2:465–471.

69. Gottlob I, Stangler-Zuschrott E. Effect of levodopa on contrast sensitivity and scotomas in human amblyopia. Invest Ophthalmol Vis Sci. 1990; 31:776–780.

70. Pediatric Eye Disease Investigator Group. Repka MX, Kraker RT, et al. A randomized trial of levodopa as treatment for residual amblyopia in older children. Ophthalmology. 2015; 122:874–881.

71. Pawar PV, Mumbare SS, Patil MS, Ramakrishnan S. Effectiveness of the addition of citicoline to patching in the treatment of amblyopia around visual maturity: a randomized controlled trial. Indian J Ophthalmol. 2014; 62:124–129.

72. Campos EC, Bolzani R, Schiavi C, et al. Cytidin-5'-diphosphocholine enhances the effect of part-time occlusion in amblyopia. Doc Ophthalmol. 1996-1997; 93:247–263.

73. Campos EC, Schiavi C, Benedetti P, et al. Effect of citicoline on visual acuity in amblyopia: preliminary results. Graefes Arch Clin Exp Ophthalmol. 1995; 233:307–312.

74. Razeghinejad MR, Nowroozzadeh MH, Eghbal MH. Levodopa and other pharmacologic interventions in ischemic and traumatic optic neuropathies and amblyopia. Clin Neuropharmacol. 2016; 39:40–48.

75. Putignano E, Lonetti G, Cancedda L, et al. Developmental downregulation of histone posttranslational modifications regulates visual cortical plasticity. Neuron. 2007; 53:747–759.

76. Smith GB, Bear MF. Bidirectional ocular dominance plasticity of inhibitory networks: recent advances and unresolved questions. Front Cell Neurosci. 2010; 4:21.

77. Wong AM. New concepts concerning the neural mechanisms of amblyopia and their clinical implications. Can J Ophthalmol. 2012; 47:399–409.

78. Tsirlin I, Colpa L, Goltz HC, Wong AM. Behavioral training as new treatment for adult amblyopia: a meta-analysis and systematic review. Invest Ophthalmol Vis Sci. 2015; 56:4061–4075.

79. Vagge A, Nelson LB. Amblyopia update: new treatments. Curr Opin Ophthalmol. 2016; 27:380–386.

80. Holmes JM, Beck RW, Kraker RT, et al. Risk of amblyopia recurrence after cessation of treatment. J AAPOS. 2004; 8:420–428.

81. Rutstein RP, Fuhr PS. Efficacy and stability of amblyopia therapy. Optom Vis Sci. 1992; 69:747–754.

82. Scott WE, Dickey CF. Stability of visual acuity in amblyopic patients after visual maturity. Graefes Arch Clin Exp Ophthalmol. 1988; 226:154–157.

83. Gunton KB. Advances in amblyopia: what have we learned from PEDIG trials? Pediatrics. 2013; 131:540–547.

84. De Weger C, Van Den Brom HJ, Lindeboom R. Termination of amblyopia treatment: when to stop follow-up visits and risk factors for recurrence. J Pediatr Ophthalmol Strabismus. 2010; 47:338–346.

85. Holmes JM, Melia M, Bradfield YS, et al. Factors associated with recurrence of amblyopia on cessation of patching. Ophthalmology. 2007; 114:1427–1432.